A Multicenter Cross-Sectional Study on Assessment of Depression in Cardiac Patients

ABSTRACT

Introduction:

Cardiovascular diseases (CVDs) are considered the primary cause of mortality in Saudi Arabia and it is one of the major health concerns in the country. Depression can complicate, halt or even exacerbate the process of managing CVDs, making it harder to optimize the patient’s condition. The main aim of this study is to assess the depression in cardiac patients.

Methods:

A cross-sectional observational study was conducted in 257 patients diagnosed with cardiovascular diseases. The study was conducted in two governmental hospitals in Tabuk, Saudi Arabia, from December 2021 to April 2022. Depression was assessed using the Arabic version of the CESD-R questionnaire.

Results:

The mean age of the participants was 44.49 ± 12.99 years. Majority of patients were in the age group of 40-49 years (n = 92, 35.8%). More than half (53.3%) of the samples were female. The prevalence of depression among cardiac patients was 53.3%.

Conclusion:

The prevalence of depression was high among cardiac patients. It is strongly advised that routine examination and management of depression in cardiac patients be included in their regimens.

INTRODUCTION

Cardiovascular diseases (CVDs) are considered the primary cause of mortality in Saudi Arabia and it is one of the major health concerns in the country.[1] The morbidity associated with CVDs and its impact on the patient’s quality of life make them more prone to encounter depressive symptoms during the course of the disease.[2] Depression can complicate, halt, or even exacerbate the process of managing CVDs, making it harder to optimize the patient’s condition. Depression involves multiple etiologies including biological, social, and psychological causes.[3] Depression is a common mental illness, accompanied by several characteristics such as despair, long-term sadness, and feeling of disassociation from the environment surrounding the patients. It can alter how people think and feel and it affects the person’s well-being and their social behavior. It can affect individuals of any age.[4]

In this study, we discussed the prevalence of depression in CVDs and what are the various possible contributions of several risk factors for developing depressive symptoms during the course of the illness. After a cardiac event, the patient may experience a state of depression. The sudden change in their lifestyle makes them more vulnerable, thus complicating the patient’s condition. The constant thinking of death can affect adherence to the medications therefore it can exacerbate other comorbidities. The overall deterioration increases the risk of developing depression.[5] In all age groups, depression co-occurs with a medical disease and it is linked to lower physical, mental, and social functioning than depression or physical illness alone. Co-occurrence of coronary heart disease with depression predicts a doubling of the risk of cardiac events in the years following a myocardial infarction, as well as a corresponding increase in mortality.[6]

Studies have demonstrated the crucial risk factor of depression among cardiac patients, higher risk of premature death after acute cardiac events, and also higher risk for exacerbation of nonfatal cardiac cases.[7] Depression adverse health consequences such as increased morbidity, mortality, and impairment of the physical function are all associated with cardiac disease and it has a major role in the development of these consequences.[8]

Depression was assessed among cardiac patients in Jeddah and reported that 66.9% of patients had depression.[9] Even though, several studies have discussed this topic in different countries, there is a knowledge gap regarding this subject in Tabuk. Studies have been conducted in Saudi Arabia as well, but in different cities and of single-centre study. Hence, this multi-centric study was carried out to assess the prevalence of depression in cardiac patients in Tabuk. The main objective of this study is to assess depression in cardiac patients. The primary goal is to find out the prevalence of depression among cardiac patients. The secondary goal is to find the association between age, sex, and depression.

MATERIALS AND METHODS

Study design and population

This cross-sectional observational study was conducted at the Cardiology department of two governmental hospitals, Tabuk, from December 2021 to April 2022.

Inclusion criteria

Cardiac disease patients of age ≥18 years of both sexes.

Exclusion criteria

Patients less than 18 years of age and those who are not willing to participate.

Ethical concern

Ethical approval was obtained from Tabuk Institutional Review Board (UT 077/022/115). All participants gave their consent to participate in this study.

Data collection

The demographic details and the disease condition were recorded in a data collection form. Their depression was assessed by a validated Center for Epidemiologic Studies Depression Scale – Revised (CESD-R) questionnaire. The Arabic version of this questionnaire was obtained from the author with a permission to use it.[10] The CESD-R is a depression Center for Epidemiological Studies Depression Scale, Revised, to assess depression among cardiac patients. It is a 20-item self-report questionnaire used to measure symptoms of depression. It is scored on a five point Likert scale. Questions 4, 8, 12, and 16 have a score of 0 for no depression or less than a day, 1 for 1 or 2 days, 2 for 3 to 4 days, 3 for 5 to 7 days, and 4 for nearly all days for 2 weeks. All other questions will have a reverse score. The total score of the CESD-R is calculated as the sum of the 20 items. Scores range from 0 to 60. A score ≥16 indicates that a person is at risk for clinical depression. This scale measures 9 different subscales, including:

Sadness (Dysphoria): (Q. 2, 4, 6), Loss of Interest (Anhedonia): (Q. 8, 10), Appetite: (Q. 1, 18), Sleep: (Q. 5, 11, 19), Thinking/concentration: (Q. 3, 20), Guilt (Worthlessness): (Q. 9, 17), Tired (Fatigue): (Q. 7, 16), Movement (Agitation): (Q. 12, 13), Suicidal Ideation: (Q. 14, 15).

Statistical analysis

SPSS version Armonk, NY: IBM Corp. database version 21 was used. Pearson’s correlation was performed to assess the correlation between age and depression. Pearson’s Chi-square test was performed to assess the association between gender and depression. P < 0.05 was considered statistically significant.

RESULTS

Depression was assessed in 257 cardiac patients. The prevalence of depression among cardiac patients was 53.3%. More than half (53.3%) of the sample were female. Our sample size age ranges from 20 to 85 years old, the mean age of the participants was 44.49 ± 12.99 years. Majority of patients were in the age group of 40-49 years (n = 92, 35.8%). The demographic characteristics of the participants were shown in Table 1.

Table 1.

Sociodemographic characteristics of the participants

Patient characteristics	Number (%)
Age in years
18-29	37 (14.4)
30-39	35 (13.6)
40-49	92 (35.8)
50-59	63 (24.5)
60+	30 (11.7)
Sex
Male	120 (46.7)
Female	137 (53.3)
Education level
Grade 1-7	11 (4.3)
Grade 8-11	87 (33.9)
Completed High School	97 (37.7)
College	62 (24.1)
Marital Status
Married	200 (77.8)
Unmarried	57 (22.2)

Hypertension was the most common cardiac disease found in the patients (n = 124; 48.3%), followed by arrhythmia (n = 45; 17.5%) [Table 2].

Table 2.

Cardiac disease of the patients

Cardiac disease	Number (%)
Atrial Fibrillation	9 (3.5)
Arrhythmia	45 (17.5)
Arteriosclerosis	25 (9.7)
Coronary artery disease	5 (1.9)
Deep vein thrombosis	12 (4.7)
Heart Failure	21 (8.2)
Hypertension	124 (48.2)
Hypotension	3 (1.2)
Myocardial Infarction	4 (1.6)
Mitral valve regurgitation	4 (1.6)
Stroke	5 (1.9)

Depression was assessed using CESD-R questionnaire. The mean score of the participants was 19.32. Depression was categorized into subcategories like meets criteria for major depressive episode, probable major depressive episode, possible major depressive episode, sub-threshold depression symptoms, and no clinical significance.

Based on the scoring system, 137 patients (53.3%) showed a risk for clinical depression.

Out of 137 patients (53.3%) with risk for clinical depression, 82 (31.9%), 24 (9.3%), 16 (6.2%), and 15 (5.8%) were categorized as sub-threshold, possible, probable, and meets criteria for major depressive episodes, respectively. Remaining 120 patients (46.7%) showed no clinical significance [Figure 1].

Figure 1.

Category of depression

Excluding the non-significant patients, 137 patients with depression symptoms were evaluated based on the 9 subscales. There were 62 (45.3%) male and 75 (54.7%) female. Males had more sleep disturbances and tiredness. Females had more of tiredness and movement (agitation) [Table 3].

Table 3.

Distribution of the subscales based on gender

Subscales	Male	Female
Sadness	5	3
Loss of interest	4	10
Appetite	10	6
Sleep	13	11
Thinking/Concentration	4	9
Guilt	3	8
Tired	13	14
Movement	10	14
Suicidal Ideation	0	0

The correlation between age, sex, and the risk for developing clinical depression was assessed. Both age and sex have negative correlation with risk for depression. The correlation of age with risk of depression was clinically significant. Pearson’s Chi-square test was performed to assess the association between gender and depression. There was no association between gender and depression (p = 0.457).

DISCUSSION

To the best of our knowledge, this is the first study conducted in Tabuk to assess the prevalence of depression in cardiac patients using CESD-R questionnaire. The results showed that patients with cardiac diseases were more prone to develop clinical depression. In our study, the prevalence of depression was 53.3%. It was almost consistent with other studies—51%[11] and 52.8%.[12] The results of our study were different from previous studies. Less depression rates were observed in different studies—5.9%,[13] 14%,[14,15] 15%,[16] 19.9%,[17] 21.5%,[18] 23.8%,[19] 26.4%,[20] and 37%.[21] High depression rates were observed in other studies, when compared to our study result—65%,[22] 67%,[23] and 73.2%.[24] The discrepancy in the study results might be due to difference in the characteristics of the studied sample, setting, assessment tools, design of the study, and sociocultural difference. The high prevalence rate among cardiac patients necessitates routine screening of depression among cardiac patients. Also, our findings urge the compulsion of mental health integration into cardiac patients in their treatment.

Hypertension was the most common cardiac disease found in the patients of our study. This is similar to another study.[12] In our study, depressive symptoms were observed. Males had more sleep disturbances and tiredness. Females had more of tiredness and movement (agitation). This is in accordance with another study.[25] It is common that some signs and symptoms of cardiac diseases like fatigue and tiredness are observed in depression. The identification of these depressive symptoms may help in screening and intervention for cardiac patients.

Both major depressive disorders and cardiovascular diseases are linked by biological pathways that have been discovered. Stress pathway activation has been proposed as a neurochemical mechanism linking major depressive disorder and CVDs.[26] Depression has been linked to a worsening of CVD outcomes.[27] Psychological problems, such as significant depression, stress, anxiety, insomnia, anorexia, and general discomfort, are increasingly recognized as risk factors for CVDs and vice versa, which are as important as and distinct from traditional risk factors like hypertension, diabetes, and cigarette smoking.[28] Given that depression and coronary heart disease are anticipated to be two of the top three causes of global illness burden, both disorders have significant socioeconomic implications.[29] It can help with better defining and implementing more relevant treatments if we have a better knowledge of the common causal pathways. Understanding the effect and process behind the association of depression and heart disease can allow the development of treatments on altering the harmful consequences caused by these comorbid diseases.[22]

Our study reported high rates of depression in female. This is in accordance with another study.[30] But there was no association between gender and depression in our study. This is similar to another study[18] but contrast with other study,[31] which reported that depression has a significant association with patient’s gender. Difference in study setting may be the reason for this conflicting result. The association of depressive symptoms with cardiovascular and all-cause mortality were reported.[32] Based on the findings of different studies, it is strongly advised that individuals with CVDs be evaluated for depression and treated if necessary.

Depression is the major factor affecting the quality of life of cardiac patients. Cardiologists must make sure that screening and detection of depression is undertaken for all cardiac patients.

Strengths and limitations

This multi-centric study has explored the prevalence of depression among cardiac patients in Tabuk.

The major limitation of this study is convenience sampling, which may not be useful to generalize the results. Depression was assessed based on subjective information provided by the patients, and objective evidence was not assessed.

CONCLUSION

In Tabuk, Saudi Arabia, this study looked at the prevalence of depression in patients with cardiac disease. The findings of this study back up previous findings that people with cardiac diseases are at a higher risk of developing clinical depression. Furthermore, cardiac diseases were found to be predictive of developing depression. It is strongly advised that routine examination and management of depression in cardiac patients be included in their regimens.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.